Ultrarapid subthreshold stimulation for termination of atrioventricular node reentrant tachycardia

OBJECTIVES. We investigated the efficacy and safety of ultrarapid subthreshold electrical stimuli in terminating sustained atrioventricular (AV) node reentrant tachycardia. BACKGROUND. Subthreshold stimuli, singly and in trains, have been reported to prolong the effective refractory period, inhibit the response to subsequent suprathreshold extrastimuli and to terminate ventricular tachycardia and reciprocating tachycardia. METHODS. Seventeen consecutive patients with inducible sustained slow-fast AV node reentrant tachycardia (mean tachycardia cycle length 358 +/- 61 ms) were studied. Trains of subthreshold stimuli were tested at various right atrial sites. RESULTS. Trains of subthreshold stimuli reproducibly terminated AV node reentrant tachycardia in 15 patients without administration of adjunctive pharmacologic agents. Effective subthreshold current strength ranged from 0.5 to 1.5 mA (mean 0.9 +/- 0.3). The cycle length of effective subthreshold stimuli trains ranged from 30 to 80 ms (mean 57 +/- 17), and the number of stimuli in the train ranged from 4 to 16 (mean 8 +/- 4). The site of successful termination was the proximal coronary sinus in 6 patients and the right low atrial septum in 12. During successful subthreshold termination, no atrial capture could be detected. Neither atrial fibrillation nor flutter nor tachycardia acceleration occurred. CONCLUSIONS. Low current, high frequency trains of stimuli, when applied at a site presumed to be close to the reentrant circuit, provided a safe and effective method of terminating the common type of AV node reentrant tachycardia. This technique could be used to identify critical parts of the reentrant circuit suitable for ablation and further investigations with this method are warranted